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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF < THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF !MANCE
<br />1/4/2021
<br />LINCOLN, NEBRASKA
<br />202200543
<br />0: '/a /4,11 xlf.,/ _<71.+ ,et r11.
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Emil Obermiller
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St. Paul, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-68-4534
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />eb. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />72
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑ ER/outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />20 18857
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 27, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 6, 1948
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9b. COUNTY
<br />Buffalo
<br />9c. CITY OR TOWN
<br />Ravenna
<br />❑Hospice Facility
<br />9d. STREET AND NUMBER
<br />610 Buffalo Lake Road
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68869
<br />9g. INSIDE GITY LIMITS'.
<br />❑ YES ® NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Vicki Lynn Williams
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHERS -NAME (First,
<br />Emil Obermiller JI Anna Haqmann
<br />Middle, Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />®'Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Vicki Obermiller
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />16b. LICENSE NO.
<br />1071
<br />16c. DATE (Mo., Day, Yr.)
<br />January 4, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Soulville Cemetery
<br />CITY / TOWN
<br />Boelus
<br />STATE'.
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths f=uneral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />18. PART I. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAUBE 040 a)Adult Respiratory Distress Syndrome
<br />disuse or condition resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on One a
<br />tinter.the UNDEIRLYING Ouse
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />to) Multifocal Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) COVID 19
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset.** death
<br />3 Weeks '
<br />onset to death
<br />3 Weeks
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART If. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Hypertension, Benign Prostatic Hyperplasia
<br />19. WAS MEDtCAL EXAMINER
<br />OR CORONER CONTACTED? I'
<br />❑ YES kJ NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown if pregnant within the past year
<br />21a. MANNER. OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES j NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DAIS OF INJURY (Mo, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc
<br />(Bpecl )
<br />22d. INJURY AT WORK?
<br />❑YES; ❑NO.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN
<br />FX
<br />F W
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 27, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 29, 2020
<br />23c. TIME OF DEATH
<br />09:11 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and TRA)
<br />Manoi Suryanarayanan, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEAN?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE '>
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24a. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Titre)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO?
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Manoj Suryanarayanan, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE `3
<br />>G',4a}.7
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 30, 2020
<br />
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